Plantar Fasciitis Treatment - an excerpt from Craig Payne posted on the Podiatry Arena

This is an excerpt from a posting by Craig Payne - Senior Lecturer at La Trobe University in Australia from the Podiatry-Arena forum.  It is reposted with his permission.  Special thanks to Peter Bird for bringing this forum posting to my attention.  Pictures were added by me, to help illustrate.  The original posting had no photos or illustrations.


Ok, Mr Runner, you have got plantar fasciitis. Plantar fasciitis occurs when the load in the plantar fascia exceeds what the tissue can take, so we have only two things we can do. One is reduce the load and the other is increase the ability of the tissues to take the load. Reducing the load is easy and is something we can do today. Increasing the ability of the tissue to take the load is more difficult, takes time and is not something we can do in the short term.

[caption id="attachment_2329" align="alignright" width="300"] Low Dye Strapping -  photo from http://conejofeet.com/patients-guide-heel-pain/[/caption]

I know you have a marathon to run in 4 weeks. Is the plantar fasciitis interfering with your preparation for that? If it is, then we will use low dye strapping today to get a more acute effect of reducing the load. At least that will help the symptoms and start the healing process while we keep an eye on that marathon preparation. We are also going to use foot orthotics to reduce the load. I know you have read on a blog post that orthotics are evil (and minimalism is the second coming of the messiah), but the reality is that every single outcome study on foot orthotics says they work (except for one when used to treat bunions in kids, but that obviously does not apply to you). It is irresponsible to not do what the evidence says. Not all foot orthotics are created equal and there are specific design features that they need to ensure that they do lower the load in the plantar fascia (if they do not achieve that, then the chance of a failure is increased). I know you read on a blog post that orthotics weakened muscles, but the all the published research (3 studies now) have shown that this is not the case, in fact, two of the studies actually shows foot orthotics strengthen the muscles, so would you rather believe the scientific evidence or an anonymous blog post from someone who has no clinical experience?

[caption id="attachment_2332" align="alignleft" width="225"] Stretching photo from: http://conejofeet.com/patients-guide-heel-pain/[/caption]

We also going to get you to do a lot of stretching for the calf muscles and plantar fascia. You are going to do it 4-5 times a day, without fail! It is extremely important! I am also going to mobilize your fibula to make sure there is no inhibition there and if your calf muscles are tight, probably use a heel raise in the very short term. As soon as possible we want to get rid of the heel raises, but they important now to overcome the tightness until the stretching kicks in. The evidence also tells us how effective stretching is and we want to give you the best chance to get through that marathon.

Keep up with the ice applications after running.

I expect this to get you through the marathon in 4 weeks. If after a couple of weeks it is not improving as fast as we would like, then we may add some night splints to further stretch and even consider a cortisone shot (if you did not have the marathon coming up, maybe would not do this). At that stage we may also consider some other things to help the tissues heal (eg Graston, trigger point therapy; deep friction; or even shockwave). However, most of those types of treatment do not reduce the load in the plantar fascia or improve the ability of the tissues to take the load; all they do is facilitate the healing of the damaged tissues. We still need to get load down and/or increase the ability of the tissues to take that load.

Say what? You read on a blog post that minimal running is the best treatment for plantar fasciitis as weak muscles is the cause of plantar fasciitis!! What would you rather believe, a blog post or the evidence. There is no evidence that weak muscles are related to plantar fasciitis (I have never seen it). There is even evidence that minimalistic running does not strengthen the muscles. One randomised control trial reported that there was no statistical difference between minimalist shoes and regular shoes for plantar fasciitis, but there was a trend to the minimalism group doing better. But, if you read the actual paper rather than the abstract you will see that they left out of the analysis several in the minimalist group who got so bad they had to withdraw from the study. Having said that, if you want to go down that pathway, it is your choice and we will assist you with the transition etc.

You asked about running form and plantar fasciitis? Running form or technique is extremely important, not only for injury prevention and performance. There is no data linking plantar fasciitis to any particular running form or foot strike pattern. It appears to me to occur in all different running forms and foot strikes, so changing your running form is probably not going to help or hinder your plantar fasciitis. There are other injuries that do benefit from changing the running technique one way or another. Having said that, when I watched you run, there were a couple of issues you might want to consider addressing over the longer term. If you are interested I can refer you to some people who know a lot more about running technique than me. They are sensible in their approach and do not promote a nonsensical agenda.

[caption id="attachment_2333" align="alignright" width="275"] image from: https://www.healthtap.com/#topics/orthotics[/caption]

You asked about stengthening exercises? Strength is important for running, but there is not one shred of evidence linking muscle weakness to plantar fasciitis (apart from blog posts by people who have no clinical experience actually treating people with plantar fasciitis). What those bloggers seem to miss is that a weakness of the intrinisic muscles of the foot actually lead to a higher arched foot and not a flat foot that they claim. I can give you some exercises if you inclined to do them. Even if plantar fasciitis is due to weaker muscles, we need to fix your plantar fasciitis now; strengthening exercises will take many many months to have an effect, even if they have any effect on this! And besides, we know from the evidence that foot orthotics can strengthen the muscles, so why not use those?

Now we got you through the marathon, what are we going to do in the long term? It is really up to you. There is nothing wrong with continuing to wear the foot orthotics if you want to and they make you more comfortable. There is no evidence that they do any harm. The evidence is that they do not weaken the muscles and they actually make the muscles stronger. Plenty of people wear them long term and never have problems, but also plenty of people rant about them in forums and on blogs, but they ignore what the evidence says which does their credibility no good. If you look at all the outcome studies on foot orthotics and there success rates, they are no different than any other medical intervention for almost any other medical condition. Of course there will be failures. There are failures in knee replacement surgery; in using antibiotics for strep throat; etc. Should we not use knee replacement surgery or antibiotics because sometimes there is a failure? Sometimes foot orthotics fail. This could be due to the wrong design being used or the runner not following the proper advice. The overwhelming evidence from all the outcome studies is that they work. The problem is that when a foot orthotic fails, the runner goes on to a forum to rant about it. No one rants about a knee replacement surgery failure or antibiotic failure … don’t figure!

We do need to put in place a strategy to increase the tolerance of the plantar fascia to the loads that are placed on it, so we will give you a plan for that. It is really up to you how much effort you want to put into this. Hopefully as the orthotics bottom out, your plantar fascia is adapted to the load and does not become a problem again and you do not need the orthotics. However, sometimes the magnitude of the forces on the tissue are so high that the tissues cannot adapt and you may need foot orthotics over the longer term to keep the load on the plantar fascia down to a level that the tissues can tolerate. That is not a problem and it won’t make you infertile, blind, or go bald or anything like that.

It is up to you. If you want to transition to minimalism running, that is fine, it will probably not impact on your plantar fasciitis. There is nothing wrong with minimalism; there is nothing wrong with maximalism. It all depends on your choices and what tissues you need to offload over the longer term. Different running forms load different tissues. It also depends on what feel you want under your feet. If you want to feel something soft, then that is fine. If you want to feel the ground more, then that is fine. Just do not fall for all the rhetoric and propaganda and the misuse of science.

the full forum posting can be seen at: http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=83788